ANCA-associated giant cell arteritis presenting with mononeuritis multiplex and central retinal artery occlusion: a case report

From Temporal Cell Arteritis to Giant Cell Aortitis Presenting as a Constitutional Syndrome: A Case Report

Giant cell arteritis (GCA) is the most common form of systemic vasculitis in adults, especially in patients over the age of 50. It manifests most commonly with an intense headache and visual symptoms. Although constitutional symptoms are also frequent in GCA, these can be dominant in 15% of patients at first presentation and 20% of patients when relapsing. Treatment with high-dose steroids should be initiated as soon as possible to rapidly control the inflammatory symptoms and prevent ischemic complications, the most feared being blindness from anterior ischemic optic neuropathy. We present a case of a 72-year-old man who presented to the emergency department with a right temporal headache with retroocular radiation associated with scalp hyperesthesia, without any visual symptoms. The patient also reported low-grade fever, night sweats, anorexia, and weight loss over the last two months. The physical exam revealed a tortuous and indurated right superficial temporal artery, which was tender to palpation. The ophthalmological examination was normal. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated, and he also had inflammatory anemia with a hemoglobin of 11.7 g/L. Due to this clinical presentation as well as the elevation of inflammatory markers, the diagnosis of temporal arteritis was suspected, and the patient was started on prednisolone (1 mg/kg). A right temporal artery biopsy was performed on the first week after the initiation of corticotherapy and was negative. After treatment initiation, there was a remission of symptoms accompanied by a decrease and normalization of inflammatory markers. However, after steroid tapering, there was a reappearance of constitutional symptoms but without any other organ-specific symptoms, such as headache, visual loss, arthralgia, or other. The corticosteroid dose was increased to the initial dosage, but there was no improvement in the symptoms this time. After the exclusion of other causes of the constitutional syndrome, a positron-emission tomography (PET) scan was performed, which showed a grade 2 aortitis. The diagnosis of giant cell aortitis was assumed, and given the lack of clinical response to corticotherapy, tocilizumab was initiated with a resolution of constitutional symptoms as well as a normalization of inflammatory markers. In conclusion, we report a case of temporal cell arteritis that further progressed to aortitis manifesting solely with constitutional symptoms. Furthermore, there was no optimal response to corticotherapy and no improvement with tocilizumab, therefore making this a case with a unique and infrequent clinical course. GCA is characterized by a wide variety of symptoms and organ involvement, and although it most frequently affects temporal arteries, it can be associated with aortic involvement that can cause life-threatening structural complications, highlighting the need for a high suspicion index for this condition.

Clinical comparisons of patients with giant cell arteritis with versus without fever at onset

Objective

Giant cell arteritis (GCA) is the most common systemic vasculitis in individuals aged ≥50 years. Some patients with GCA who develop fever at onset without typical ischemic manifestations may be misdiagnosed with fever of unknown origin.

Methods

In the present study, we retrospectively evaluated the clinical records of patients with GCA. Patients with and without fever at onset were compared.

Results

This study included 91 patients with GCA, 55 of whom had fever at onset. The patients with fever at onset showed a lower frequency of jaw claudication and arthralgia and a higher percentage of constitutional symptoms than patients without fever. Additionally, their laboratory results revealed a lower percentage of positive anti-neutrophil cytoplasmic antibody. Furthermore, a lower proportion of affected intracranial vessels was found in patients with fever at onset. Finally, the proportion of biopsy-positive cases was higher in patients with than without fever at onset.

Conclusions

In this study, 60.4% of patients with GCA had fever at onset. Patients in this group usually had more severe inflammation with a potentially lower risk of ischemic accidents of the central nervous system than patients without fever at onset.

Branch retinal artery occlusion in the untreated contralateral eye following aflibercept injections during heparin treatment: Possible contribution of a heparin-induced thrombocytopenia-like condition

PURPOSE

In this study, we report a case of branch retinal artery occlusion (BRAO) in the contralateral eye the day after aflibercept treatment during systemic heparin administration.

OBSERVATIONS

A 63-year-old woman with diabetic macular edema underwent repeated intravitreal injection of anti-VEGF drugs (0.5mg ranibizumab or 2mg aflibercept) for her left eye. The day after intravitreal injection of aflibercept, she presented with sudden painless blurred vision that was limited to the inferior visual field defect in the contralateral eye (right eye) during hemodialysis with the anti-coagulant heparin. Optical coherence tomography angiography (OCTA) showed decreased artery perfusion and the patient was diagnosed with contralateral BRAO.

CONCLUSIONS

Previous in vitro and in vivo studies have reported that the Fc portion of anti-VEGF drugs activates platelets with heparin. Therefore, careful anti-VEGF drug selection may be necessary in cases with concomitant heparin treatment.